Signed (Treating Dentist) Date Specialty Code Number ©2006 ...
[Pages:1]ADA Dental Claim Form Sample
Unless the following sections of a dental bill are completed correctly, the bill will be returned and payment may be delayed.
Field
Section
Information Required
1 Header Information
Type of Transaction
12 Policyholder/Subscriber Information Name and Address
15 Policyholder/Subscriber Information ID (SSN / ID #)
18 Patient Information
Relationship to Policyholder/ Subscriber in box 12
20 Patient Information
Patient Name and Address
24 Record of Services Provided
Procedure Date
27 Record of Services Provided
Tooth Number(s) or Letter(s)
29 Record of Services Provided
Procedure Code
30 Record of Services Provided
Description
31 Record of Services Provided
Procedure Code Fee Amount
32 Record of Services Provided
Total Charges/Billed Amount
48 Billing Dentist or Dental Entity
Name and Address
50 Billing Dentist or Dental Entity
License Number
51 Billing Dentist or Dental Entity
Tax ID/SSN/FEIN Number of Payee as Registered with the IRS
52 Billing Dentist or Dental Entity
Phone Number
53 Treating Dentist and Treatment Location Information
Signature and Date
55 Treating Dentist and Treatment Location Information
License Number
56 Treating Dentist and Treatment Location Information
Address where services were rendered if different than box 48
57 Treating Dentist and Treatment Location Information
Phone Number if different than box 52
The CalVCB Claim Number must be written on the ADA Dental Claim Form.
For providers already in CalVCB's system: Number 48 and Number 51 on your bill must match exactly to what is in the system. If you have a new Tax ID, please notify CalVCB immediately.
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